What are the pharmacologic treatments for Essential Tremor (ET)?

Pharmacologic Treatments for Essential Tremor

Propranolol is the first-line pharmacologic treatment for essential tremor, with efficacy in approximately 50% of patients. 1

First-Line Treatments

Beta-Blockers

• Propranolol

  • Mechanism: Blocks beta-1 and beta-2 adrenergic receptors
  • Dosage: Start at 40 mg twice daily, maximum 240 mg daily 1
  • For mild, situational tremor: 20-40 mg as needed before anxiety-inducing situations
  • For elderly patients: Start lower (10-20 mg twice daily) and titrate slowly 1
  • Efficacy: Improves tremor in all treated patients, most pronounced in upper extremities 2
  • Advantages: Well-established efficacy, can provide dual benefit for patients with hypertension 1

• Alternative Beta-Blockers (if propranolol not tolerated)

  • Metoprolol: Less effective but better option for patients with respiratory concerns
  • Atenolol: Fewer central nervous system effects
  • Nadolol: Alternative for patients with contraindications to propranolol 1

Anticonvulsants

• Primidone
  • Can be used as first-line alternative to propranolol
  • Can be combined with propranolol if either medication alone provides inadequate control 3

Second-Line Treatments

Combination Therapy

• Propranolol + Primidone: Consider if monotherapy with either medication provides inadequate control 3

Benzodiazepines

• Clonazepam: May provide benefit if primidone and propranolol do not provide adequate control 3
• Caution: Risk of dependence and cognitive side effects

Other Anticonvulsants

• Gabapentin
  • Dosage: 300-2400 mg daily divided into three doses
  • Particularly effective for patients with comorbid neuropathic pain 1
• Topiramate: Consider if other treatments fail 3

Treatment Algorithm

1. Initial Assessment:

   • Determine if tremor causes functional disability
   • If tremor is only disabling during stress/anxiety: Consider as-needed propranolol

2. First-Line Treatment:

   • Start with propranolol 40 mg twice daily (lower dose for elderly)
   • OR primidone if propranolol is contraindicated

3. Inadequate Response to First-Line:

   • Increase propranolol dose up to 240 mg daily
   • OR switch to alternative beta-blocker if side effects occur
   • OR add primidone if propranolol alone is insufficient

4. Inadequate Response to Combined First-Line Treatments:

   • Add benzodiazepine (clonazepam)
   • OR try gabapentin or topiramate

5. Refractory Tremor:

   • Consider surgical options (deep brain stimulation or thalamotomy) if medications fail to provide adequate control

Special Considerations

• Monitoring: Clinical evaluation of effect is sufficient; plasma concentration monitoring has little value 4
• Duration of Trial: Allow at least 2-4 weeks to assess efficacy of treatment 5
• Comorbidities:
  • Hypertension: Beta-blockers provide dual benefit
  • Migraine: Propranolol, metoprolol, and timolol are effective for both conditions 1

Important Caveats

• Current medications improve tremor in only about 50% of patients 3
• No available medications can cure essential tremor or slow its progression 3
• Surgical options (deep brain stimulation or thalamotomy) provide adequate tremor control in approximately 90% of patients with refractory tremor 3
• Selective serotonin reuptake inhibitors (SSRIs) are not recommended due to lack of evidence supporting efficacy 1

Remember that the goal of treatment is to reduce functional disability from tremor. If the initial treatment doesn't provide adequate relief, don't hesitate to move to combination therapy or alternative options rather than persisting with an ineffective regimen.